HULC (ORTHOPEDICS/PLASTIC SURGERY)

Transcription

1 Rotation Specific Learning Objectives CCFP(EM) Residency Program Schulich School of Medicine & Dentistry HULC (ORTHOPEDICS/PLASTIC SURGERY) To utilize the relevant competencies contained within the CanMEDS-FM roles to effectively evaluate, diagnose and develop the procedural skills necessary to manage the patient under the Plastic Surgery and Orthopedic service, with special emphasis on those clinical presentations common to the Emergency Department involving the upper extremities. Specific Educational Objectives Role of Family Medicine-Emergency Medicine (FM-EM) Expert The resident will develop expertise in the ability to: Develop relevant history and physical exam skills for assessing patients referred to a plastic surgery or orthopedic service. Develop expertise in the use of the diagnostic imaging modalities available for the evaluation of plastic/orthopedic disorders. Develop the technical skills necessary to definitively manage the patients who present with surgery problems that fall within the realm of responsibility of an emergency physician Develop a familiarity with the technical skills necessary to definitively manage patients who present with surgery problems that fall within the realm of responsibility of a surgeon. Wounds Describe the sequence of and develop an understanding of the factors influencing normal wound healing Describe appropriate suture materials, techniques, and the timing of suture removal for the following wounds: Face, scalp, ears, trunk, extremities, tongue, fascia/muscle.

2 List treatment considerations (e.g., potential complications) in the care of animal and human bites. List possible complications and infections associated with the closure of wounds in the emergency department. List factors that increase risk of wound infection. Describe techniques of appropriate wound preparation and describe proper wound care instructions. Discuss the appropriate tetanus immunization regimen for different wounds. Develop expertise in the assessment and management of pressure sores Foreign Bodies List specific complications and difficulties related to foreign body removal for glass, wood, organic material and chemicals. Describe techniques for identification and removal of a foreign body Needlestick Injuries Outline the major steps and criteria in evaluating a patient with a needlestick injury. Burns Develop an approach to the identification and treatment of electrical burns and discuss the associated injuries. List a prioritized, evaluative and treatment protocol in a patient with thermal burns. Describe the evaluation of the magnitude of the burn injury with an estimation of the burn surface area and depth, and classification of the burn as critical, moderate, or minor. List the criteria for referral to a burn center Determine the appropriate fluid replacement therapy for a major burn patient according to a standard replacement fluid formula. List depth, region, and surface area criteria for major burns to identify those requiring admission. Cite possible complications of burn injuries. For a patient with a thermal burn not requiring admission; describe appropriate outpatient management. Compare and contrast frost nip and frost bite and outline the evaluation and treatment of patients injured with frostbite. Trauma List the immediate considerations in the acutely injured patient who has sustained upper extremity injuries, including injuries to the face and neck Describe the initial care, diagnosis, and treatment of soft tissue injuries of the face, including the following areas and topics: Anaesthesia (to include the pros and cons of epinephrine, the selection and placement of regional blocks and use of topical agents and techniques).

3 Bites, contusions, abrasions, tattoos, retained foreign bodies, puncture wounds, simple lacerations, avulsion flaps. Demonstrate expertise in the regional anesthesia of the face including the blocks to the infraorbital nerve, supraorbital nerve, mental nerve and ear blocks, and regional anesthesia of the arm, including blocks to unlar nerve, radial nerve, median nerve, and digital nerves. Develop an understanding of the regional anatomic considerations of injuries to the arm and associated nerves, glands, ducts and muscles. Given a patient with either a blunt or penetrating injury to the neck, describe the 3 anatomical regions and their importance to the wound. Develop and understanding of anatomic considerations and treatments for repair of external ear injuries. Outline a prioritized, evaluative and treatment protocol for a patient with facial bone fractures Classify the following facial fractures and discuss their diagnosis and treatment: Lefort I, II, and III, zygoma, mandible, nose, orbit including blowout and tripod injuries. Given a patient with a traumatic injury to the scalp or forehead, discuss the initial evaluation, hemostasis, regional anaesthesia, and repair of the scalp, forehead and Injuries involving galea and bony structures. Upper extremity Demonstrate knowledge of the bony anatomy. Describe the motor and sensory innervation the arm, nerve roots and peripheral nerves. Describe the compartments of the hand and arm, as well as the fascial planes. Describe the motions of the thumb. Describe the assessment of the flexor digitorum profundus and superficialis. Describe the extensor zones of the hand. Demonstrate management of fractures and dislocations of phalanxes. Describe management of metacarpal shaft and neck fractures. Describe the mechanism of injury and management of mallet fingers and boutonniere deformity. Describe gamekeeper thumb injury and outline management. Demonstrate extensor tendon repair in the hand including appropriate suture selection and arrangement of local resources for rehabilitation Describe management of partial and full digit amputation. Demonstrate knowledge of how to transport amputated tissue. Demonstrate expertise in the management of partial amputation revision of digits Differentiate between felon, paronychia and whitlow and describe the management of each. Describe the signs and management of tenosynovitis. Develop expertise in the management of injuries to the nailbed and associated structures

4 Describe how to examine, identify, and manage isolated upper limb fractures and dislocations, degenerative, overuse and traumatic tendon injuries Describe management of carpal fractures and dislocations, including disruption of the DRUJ Describe management of ulnar and/or radial bone fractures, including complications (open vs closed, compartment syndrome, neurovascular compromise Describe management of elbow fracture/ dislocations, including supracondylar injuries in pediatrics, pulled radial head, and potential complications. Describe management of humeral shaft and neck fractures, appropriate immobilization Describe identification and management of shoulder dislocations and potential complications. Appropriate use of analgesia, different techniques of relocation and complications that may arise. Describe and interpret plain radiographs of the extremity or aspirate a joint when appropriate The resident will develop expertise in the following skills: Local and Regional Anaesthesia Outline the factors involved in the choice of anaesthetic agents, toxicity, expected duration, and decision between regional block, field block, or topical anaesthesia, as well as the choice of use of epinephrine. Procedural Skills Simple sutures, running sutures, mattress stitch (both horizontal and vertical), layered closures, subcuticular closure, Z plasty, simple skin grafts, excision of the dog ear. Demonstrate closure techniques of vermillion border of lip, tongue and ear laceration repair, and extensor tendon repair Reducing bony injuries when appropriate, including dislocations to the joint and angulated/unacceptable fractures (carpal, metacarpal, colles, midshaft forearm fractures, slipped radial head injuries in pediatric patient, dislocated shoulder) Use of finger traps for bone reduction, hematoma blocks, and conscious sedation Appropriate knowledge and application of immobilizing devices where indicated ( sling, shoulder immobilizer, sugar-tong splint of the humerus, posterior slab of the elbow, forearm cast, scaphoid cast, thumb spica cast, finger splints) Aspiration/injection of the subacromial bursa, elbow joint, wrist joint

5 Role of Communicator The resident will act to facilitate the doctor-patient relationship and establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy. The resident should demonstrate expertise in the ability to: Take into account the patient's own experience of the injury (feelings, expectations, ideas) and the impact of the illness on the lives of patients and families, considering such factors as age, gender, socio-economic status, cultural and religious/spiritual values. Establish and maintain a therapeutic relationship with patients, their families and the medical team while fostering an environment characterized by understanding, trust, empathy and confidentiality Overcome barriers to communication such as language, patient disabilities, cultural differences and age group differences Develop expertise in the written documentation of injuries on the plastic surgery service including reasonable illustration. Develop the expertise to be able to describe the salient features of a patient s injury to a plastic or orthopedic surgeon Keep thorough, legible and accurate records. Deliver information to the patient and family in a humane manner and in such a way that it is understandable, encourages discussion and promotes patient s participation in decision-making to the degree that they wish. Role of Collaborator The resident will work cooperatively with patients, their families, and other members of the healthcare team to achieve optimal patient care. Special emphasis will be given to communication between the emergency department, peripheral referring sites and the consulting plastic/ortho surgery service. The resident will develop expertise in the ability to: Develop a care plan for a patient they have assessed, including investigation, treatment and continuing care, in collaboration with the members of the interdisciplinary team.

6 Participate in interdisciplinary team meetings, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing specialty-specific expertise him/herself. Develop expertise in the ability to determine which patients can be safely managed by Emergency Department personnel and which patients require referral to the HULC surgeon Maintain collegial and respectful relationships with medical and para-medical staff. Respect team ethics, confidentiality and professionalism Demonstrate an ability to promote the autonomy of patients and families and to promote their involvement in decision-making. Role of Manager The resident will play a central role in the organization of the care delivered to the patient being cared for by the HULC surgery service. They will coordinate the members of the health care system and utilize resources in a way that sustains and improves the health of their patient population The resident will develop expertise in the ability to: Effectively manage the care of multiple patients while working in the Emergency department, the wards, the recovery room and operating room. Make clinical decisions and judgments based on sound evidence for the benefit of individual patients and the population served. Effectively use patient-related databases, access computer- based information and understand the fundamentals of medical informatics. Role of Health Advocate The resident will use their role as a resident on the HULC surgery service to influence and advance the health and wellbeing of patients The resident will develop expertise in the ability to: Identify the patient's status with respect to one or more of the determinants of health (i.e., unemployment), adapting the assessment and management accordingly Assess the patient's ability to access various services in the health and social system so as to promote health, enhance understanding, foster coping abilities, and enhance active participation in informed decision-making, including

7 expertise in the ability to arrange follow up for injuries addressed by the surgery service including: Burns and frost bite Hand and upper limb injuries Complex wound care Infected wounds Role of Scholar To demonstrate a commitment to self-learning and the creation, translation, and dissemination of medical knowledge. The resident should be able to: Identify their learning needs and make use of available learning resources. Demonstrate critical thinking and integrate critical appraisal of the literature into the bedside approach. Develop an understanding of evidence based medicine as it relates to the Plastic/ Ortho Surgery patient. Demonstrate an enthusiasm for learning. Apply new knowledge to daily practice. Seek out assistance of colleagues and peers if applicability of literature to clinical practice is unclear Train undergraduate and junior post-graduate trainees Role of Professional To display commitment to an ethical practice and high personal standards of behavior in a manner that is commensurate with the importance of the doctorpatient relationship. The resident will display professional attitudes and behaviors, including: Being punctual for clinics, rounds, family conferences, and educational events Following through on assigned tasks Being respectful, honest and demonstrating compassionate care when dealing with patients, families, and other professionals. Considering personal and cultural issues in selecting treatment regimens for patients Demonstrating responsibility by being reliable and dependable

8 Demonstrating good self-assessment ability in being aware of one's own limitations and seeking feedback. Understanding the consent and surrogate decision making process Demonstrating respect of the learning opportunities available from all aspects of the HULC surgery experience including the operating room, post-op ward, emergency department, office and outpatient clinic